As in most disasters of this type, so soon after the incident, information concerning the nature of this incident is far too sketchy to draw any firm conclusions. Indeed, at the time of writing there are more questions than answers. In my previous two blogs I reported what we currently know about the Sewol disaster, based on current media accounts and issues that hampered the evacuation of the passengers on the Sewol. In the media blame is being firmly placed on the captain and bridge crew, but are these few people truly the only responsible for this tragedy? Is there a wider problem that is the root cause of this and similar disasters? In this blog I explore these issues.

The latest reports from South Korea now suggest that of the 476 people on board the Sewol, 174 were rescued, 159 bodies have been recovered and 143 people are still missing.

BLAME GAME:

It is human nature to want to blame someone after a tragedy. But when a disaster of this magnitude occurs, it is time for a nation as a whole to reflect on its safety culture, and not simply blame a few individuals. We should be looking at the safety culture on board the Sewol, in the company that owns and runs the vessel, within the South Korean maritime industry and within South Korean culture as a whole. It is far too easy to point a finger at a few people, as the South Korean President has done. To address the real problem and ensure that this type of disaster never happens again, we must identify and address the root cause(s) of the problem and this is likely to be the result of a number of factors, beyond the immediate actions of the Captain and crew.

PREVIOUS DISASTERS:

To put this disaster into context it is useful to compare it to two other Ro-Ro ferries that have capsized in recent history resulting in large loss of life. In 1987 the Herald of Free Enterprise rolled over shortly after leaving port due to her bow doors being opened in less than 4 minutes and claimed the lives of 94 people while in 1994 the Estonia capsized in rough seas within about 15 minutes and claimed the lives of some 850 people. So Ro-Ro vessels such as the Herald of Free Enterprise, Estonia and Sewol can capsize very rapidly if water gets onto the large open car decks.

HOW MUCH TIME WAS AVAILABLE?:

We believe that the crew of the Sewol first called the coast guard (CG) at 08:56 to say that they were in distress – however, it is not clear how long they waited after realising that they were in trouble before called the CG. It was reported today that the first call to the authorities was actually made by one of the children on board as he was frightened that the ship would sink. This is believed to be some 3 minutes before the crew made their first call.

From the official transcripts:

9:10 a.m.

Sewol: Jindo VTS, this is Sewol

Jindo Coastal VTS: This is Jindo Coastal VTS.

Sewol: We’re tilted, so it looks like we’ll flip over soon.

Jindo Coastal VTS: Okay. How are the people on board? Boat A is nearing your boat as fast as possible.

Sewol: With the boat now tilted at least 50 degrees to the left, people can’t move to their left or right. The crew have been told to wait with their life jackets on. But it’s impossible to check whether they’re actually wearing them. Crew members gathered on the bridge are unable to move. Please hurry up.

So at 09:10 (some 14 minutes after first official message to the CG) they state that the vessel was severely leaning over, but no firm indication as to the degree of heel apart from saying they can hardly move. At 09:17 they estimate that they are on a heel of about 50 degrees, this is some 21 minutes after the crew first contacted the CG and some 24 minutes after the child made his call.

So the vessel appears to have a severe list some 14 to 21 minutes after the crew first radioed the CG to inform them of their emergency. We do not know how long it took them to radio the CG after the incident began, but it appears to be some 3 minutes after the child on board made his call. So it appears that they may have had around 17 minutes (or more) before conditions on the vessel became very difficult.

It will be important to establish when the crew first attempted to contact the passengers and when the message to “stay where you are” was made.

Given that around 17 minutes may have been available before conditions deteriorated to the point that movement became almost impossible, it is unlikely that all 476 souls on board the Sewol would have been able to reach the assembly points from which they could relatively easily abandon the vessel. Nevertheless, had a command to commence the assembly phase been given at the earliest possible time, it is likely that considerably more of those on board could have been able to reach the assembly stations and therefore been in a position to abandon the vessel.

SAFETY CULTURE:

Given that there appears to have been sufficient time to allow a greater number of people to evacuate from the Sewol, it is important to establish the following: what were the evacuation procedures? How well did the crew know and understand them? What prevented the crew from implementing them?

These questions allude to the safety culture on the Sewol, in the management company, and in wider South Korean society, particularly:

What were the evacuation procedures on the Sewol?

How appropriate were these procedures for a Ro-Ro ferry?

Are passengers routinely informed of the evacuation procedures prior to departure?

How are they informed?

How familiar were the Captain and crew with their own evacuation procedures?

How often did the Captain and crew drill their evacuation procedures?

What did the evacuation drill consist of?

What was considered acceptable performance in evacuation drills and does this demonstrate an appropriate level of competence and understanding?

What oversight of the evacuation procedures did the parent company of the Sewol have?

What oversight of the evacuation training did the parent company of the Sewol have?

Did the corporate culture encourage or discourage adherence to safety and evacuation procedures?

What oversight of the evacuation procedures did the Korean maritime authorities have?

What oversight of the evacuation training did the Korean maritime authorities have?

Similar questions could be asked relating to other operational issues such as those relating to the safe navigation of the vessel, loading and securing cargo and rescue operations.

As in most disasters of this type, so soon after the incident, information concerning the nature of this incident is far too sketchy to draw any firm conclusions. Indeed, at the time of writing there are more questions than answers. In previous blogs related to ship evacuation, I have described the general ship evacuation process and implications for passenger ship safety; I will not repeat these here, but suggest that interested readers should refer to my earlier blogs on the Costa Cordia:

In my previous blog I reported what we currently know about the Sewol disaster, based on current media accounts. Here I will explore to explore the ship evacuation process, what hampered the evacuation of the passengers on the Sewol and some of the implications for passenger ship safety.

The latest reports from South Korea now suggest that of the 476 people on board the Sewol, 174 were rescued, 54 bodies have been recovered and 248 people are still missing.

The sinking of the Sewol bears a striking resemblance to the Costa Concordia incident. Many factors strongly influential to evacuation outcomes were common to both cases. Some of these should have assisted the passengers, while others undoubtedly impeded their safe evacuation. The common factors that should have contributed to a favourable evacuation include:

1) The incidents occurred under the jurisdiction of modern well-developed countries

This should have helped, but it does not mean that the shipping companies involved have a well-developed safety culture, or the regulatory and inspection facilities in each country are well developed and appropriate.

2) The vessels were relatively modern

The Costa Concordia was launched in 2005, and the Sewol in 1994. As both are relatively modern vessels they would have benefited from modern design practices and knowledge of safety issues. However, the Sewol was completed in the year of the Estonia disaster. This disaster lead to a number of significant changes to IMO regulations for Ro-Ro ferries such as the Sewol, but they came too late to impact the design of the Sewol.

3) The weather was calm

Bad weather can complicate the evacuation process, making it difficult to safely evacuate a large passenger vessel; however, in both cases, the sea was calm, and the conditions were not harsh. While the water temperature in the case of the Sewol incident was cool, it is unlikely that the passengers would have remained in the water for a dangerously long period of time, especially given (4), (5) and (6).

4) The vessels were on well-known routes and in busy shipping lanes

If the ship is in unfamiliar waters with little traffic it may complicate the decision to evacuate the vessel as the survivors may have to spend a long time in the water in lifeboats. However, this was not the case in either of these incidents.

5) The vessels were close to land

The fact the vessels were close to land meant that help was not far away.

6) The vessels were in radio contact with the coast guard at the time of the incident

The fact that the vessels were in contact with the coast guard from the start of the incident meant that help was be quick in arriving.

7) The vessels were not overcrowded and there were sufficient lifeboats for the population

In the case of the Sewol, the vessel was carrying significantly less than the maximum capacity of the vessel. In both cases, there was ample capacity in the available life boats.

8) The captains were experienced master mariners

Both captains had considerable experience and should have been expert in the handling of their vessels, and the dangers associated with taking on water, particularly, in the case of the Sewol, of taking on water on the car deck. Both should also have had a good working knowledge of the evacuation process and the need for speed.

Items (1) to (8) meant that the in both cases, these disasters occurred under somewhat ideal conditions and so we should have expected a much better outcome. Indeed, both cases should have been more survivable, had the evacuation been managed in a more efficient and timely manner.

In both cases the factors that contributed to the disastrous outcome of these evacuations include:

9) The passengers were not required to complete an assembly drill to familiarise themselves with the evacuation process prior to departure

In the case of the Costa Concordia an evacuation drill was not required prior to departure, but within 24 hours of departure. In the case of the Sewol, as the journey was less than 24 hours an evacuation drill was not required at all. This meant that it was unlikely that the passengers were familiar with the evacuation procedures.

10) Both Captains failed to start the assembly process within a reasonable period of time

This meant that the passengers were not in a position from where they could rapidly and easily abandon the vessel or be easily rescued by emergency responders, should this prove to be necessary.

11) Counter intuitive instructions were given to the passengers

Not only were passengers not given the command to assemble, they were effectively given instructions NOT TO assemble. In the case of the Sewol, it is reported that the passengers were instructed to stay where they were, while in the case of the Costa Concordia, passengers were told that there was not a serious problem and that they should go to their cabins.

12) Both vessels capsized but this took more than 30 minutes

In both cases, there would have been sufficient time for most, if not all of the passengers to get to their assembly stations from where they could abandon the ship, had the assembly process started sufficiently early.

13) Failure to launch sufficient lifeboats (or liferafts)

Delay in starting the evacuation process meant that it was impossible to launch sufficient lifeboats in the case of the Costa Concordia, or virtually any liferafts in the case of the Sewol. Davet launched lifeboats cannot be launched when the angle of heel exceeds 20O and the liferafts cannot be launched if the crew cannot reach them due to adverse angles of heel.

14) Both captains abandoned the vessel before their passengers and crew had safely evacuated.

In both cases it is reported that the Captain did not remain on board to manage the evacuation of the people in their care. Essentially they left the passengers to fend for themselves.

Failure to start the assembly process as soon as possible contributed to the disastrous outcome in both cases.

Why is it so important to start the assembly stage as early as possible?

In an evacuation situation, every second counts and seconds can mean the difference between life and death. On board a large passenger ship, the evacuation process is usually undertaken in two parts: the assembly phase, and the abandonment phase. This is explained in more detail in an earlier blog concerning the Costa Concordia (http://fseg.gre.ac.uk/blog/?p=110).

During the assembly phase, passengers are instructed to go to their assembly stations. Passengers will be given lifejackets at the assembly stations, or they will bring their lifejackets from their cabins. Assembly stations are close to the points from which passengers can embark onto the lifeboats if the captain decides to go to the second phase of the evacuation, the abandon ship phase. It is vitally important that the assembly phase is completed as quickly as possible because conditions on board may make it impossible for passengers to get to a place from where they can abandon the vessel, if conditions deteriorate, such as if there is a fire on board, or if the vessel is heeling over, as in the case of the Costa Concordia and the Sewol. If passengers are in the assembly stations it will also be easier for emergency teams to rescue the passengers compared to if they are located deep within the vessel.

Imagine you are in your cabin and you need to get to the assembly station. Let’s assume that the assembly station is on your deck so you don’t have to climb or descend any stairs. You will have to get out of your cabin, pass along a corridor running along the length of the vessel and then eventually pass through a corridor running across the vessel linking the left with the right part of the vessel.

When the vessel is upright, this is a relatively easy thing to do and you can pass from left to right or from right to left easily, depending on which side you need to move to (see Figure 1). If the vessel takes on a slight heel, say less than 5O, movement is still relatively easy, assuming that you are not elderly or disabled (see Figure 2); however at 20O of heel, it starts to become very difficult to move up the slope and to control your movement going down the slope (see Figure 3). Your travel speed up and down the slope is greatly reduced, resulting in it taking considerably longer to assemble the passengers. If you have elderly or disabled passengers, it is unlikely that they will be able to move unaided.

Angles of heel from 0 degrees to 20 degrees

When the angle of heel reaches 45O, it is extremely difficult to move up the slope without travelling at a crawling pace, and you will need to hold onto things such as handrails to progress (see Figure 4). Going down the slope in a controlled manner also becomes very difficult. If you are elderly or disabled, it is unlikely that you will be able to move, even with assistance.

At 60O of heel, it is unlikely anyone will be able to move up the slope, and the only way is down or staying where you are (see Figure 5). If the passengers have not reached the assembly stations by the time the angle of heel has reached 60O, it is unlikely that they are going to be able to move across the vessel against the slope.

Angles of heel from 45 degrees to 60 degrees

If passengers are still in their cabins when the heel is much greater than 20O, it is unlikely that they will be able to get out of their cabins, let alone make it to their assembly station. Imagine now that if you had to ascend or descend stairs to reach your assembly station, how much more difficult it would be, compared with simply walking along a corridor! Even walking along the long corridors running the length of the vessel becomes difficult when the ship takes on an angle of heel greater than 20O. The passenger is pulled down to the low side of the corridor and has to walk partially on the floor and partially on the bottom of the wall. Here again the speed at which the passenger can move is greatly reduced AND the effective width of the corridor is greatly reduced, making it more difficult for crowds to move along the corridor.

This is why it is essential that passengers must complete the assembly process and locate themselves in a place from which they can abandon the vessel easily or be easily rescued if necessary. So it is essential that the assembly phase of the evacuation is started as soon as possible. Assembling the passengers does not necessarily mean that they will have to abandon the vessel, but if they need to do so, they will at least be able to. I find it hard to understand why a captain of a vessel that is in distress – so much so that they have alerted the coast guard – would not have started the assembly process, if for no other reason than as a precaution. In my earlier blog concerning the Costa Concordia (http://fseg.gre.ac.uk/blog/?p=126) I offer some suggestions as why this may happen. But it may also simply be down to denial. The captain and senior officers may simply be denying the seriousness of the situation, believing that they can remedy it, and there is no need to evacuate. If so, this becomes a training issue and one concerned with safety culture, both on board the vessel and also in the operating company that runs the vessel.

Did social culture play a role in the outcome of the Sewol disaster?

It has been suggested that social culture of the South Korean people had a role to play in the outcome of the Sewol evacuation. In particular, the suggestion is that South Korean culture demands that people are respectful of authority and are compliant with the wishes of those in authority. Had the passengers been from a different cultural group they may have reacted differently to the order to stay where they were.

Recent work by my research team as part of an EU FP7-funded project BeSeCu [1,2,3] suggests that social culture may influence the way in which people respond to alarms. It was noted in this research that when faced with virtually identical situations, groups of people from one culture tended to react significantly more rapidly than groups from other cultures when faced with a fire alarm. This is further discussed in a paper we published recently with the Royal Institution of Naval Architects, concerning evacuation from large passenger ships [4], as part of the EU FP7 SAFEGUARD project [5].

However, I am not convinced that simply responding to an instruction from an authority figure is a cultural trait unique to the South Korean people. Our research into the World Trade Center evacuation [6] suggested that when people in the South Tower of the WTC heard the instructions over the PA system that they should return to their offices, as they were safe in the South Tower, (as only the North Tower had been hit at this time), many did so – and died [7]. Also, many passengers on the Costa Concordia also complied with the instructions of the crew, at least initially.

Perhaps it is more relevant that the majority of people on board the Sewol were children and so more likely to follow the commands of an authority figure. This is probably likely to be the case in most cultures. Furthermore, as with the Costa Concordia disaster, safety culture (or the lack of a healthy safety culture), as opposed to social culture, may have played a more important role in this disaster.

Assembly drill requirements

As has already been stated, according to IMO regulations, it is not compulsory to have an assembly drill prior to the departure of the vessel for voyages of less than 24 hours; however, as the Sewol and Costa Concordia incidents have tragically demonstrated, fatal accidents requiring the abandonment of the vessel can occur at any point of a voyage, even as little as a few hours after departure. In both cases, the passengers would have benefited from having experienced the assembly process prior to the fatal accident.

The point of the assembly drill is twofold: firstly, and most importantly, to familiarise passengers with the assembly procedures and the location of the assembly stations; secondly, to provide the crew with training in the management of large crowds of passengers. The need to undertake the assembly drill becomes more critical the larger the number of passengers on board, and the more complex the layout of the vessel. Indeed, the duration of the voyage is somewhat irrelevant when setting a lower limit for the need to undertake an assembly drill.

The difficulty for a regulatory body is in defining critical limits on duration of voyage, population size and complexity of vessel layout that are meaningful and not arbitrary; nevertheless, in addition to the current voyage duration criterion, sensible limits could be placed on the other factors. Addressing complexity, if a significant number of the passenger population is accommodated within cabins, the layout of the vessel will be more complex than a vessel not having cabins. Thus if a significant number of passengers are accommodated within cabins, the complexity criteria will require an assembly drill. In terms of the size of the passenger population, if the predicted assembly time for the vessel is within 20% of the maximum allowed assembly time, then the population criteria will be met to require an assembly drill.

So rather than having a single factor (duration of voyage) determining whether or not an assembly drill is required prior to departure, three factors addressing different challenging evacuation issues should be considered:

Duration of voyage: if the voyage is greater than 24 hours, an assembly drill must be undertaken. This ensures that the current criterion is maintained. The longer the voyage the greater the chance that an accident may occur and, hence, that an assembly may be required.

Complexity of vessel: if more than 30% of the passengers on the voyage are to be accommodated within cabins, then an assembly drill must be undertaken. This ensures that passengers travelling on vessels with complex layouts will undergo an assembly drill prior to departure.

Number of passengers: if the predicted assembly time for the vessel is within 20% of the maximum allowed assembly time, an assembly drill must be undertaken. This ensures that vessels with large numbers of passengers for their size will have an assembly drill prior to departure.

As in most disasters of this type, so soon after the incident, information concerning the nature of this incident is far too sketchy to draw any firm conclusions. Indeed, at the time of writing there are more questions than answers. In previous blogs related to ship evacuation, I have described the general ship evacuation process and implications for passenger ship safety so I will not repeat these here but suggest that interested readers should refer to my earlier blogs on the Costa Cordia:

Here I would like to attempt to put together a picture of what we currently know about the Sewol disaster based on current media accounts and make some tentative comments about the possible cause of the incident. In later blogs we will explore the implications of this incident on passenger safety.

As is the case after every disaster, the world’s media has been flooded with accounts concerning the sinking of the Sewol. There is so much information flying about it is difficult to keep track of the salient points of the incident. Here is what I hope a summary of some of the reported key points:

The vessel:

The Sewol was built by Hayashikane Shipbuilding & Engineering in Nagasaki, Japan in 1994.

The Sewol is a Ro-Ro ferry. She has passenger accommodation on the upper decks and a car deck lower down on the vessel. The vessel has a vehicle ramp in the aft of the vessel. The vessel can also carry shipping containers.

Vessel was bought by South Korea in October 2012.

It is owned by Chonghaejin Marine and the vessel is registered with the Korean Register of Shipping

The Sewoll was modified from Oct 2012 to Feb 2013. It is reported that additional accommodation space was added to the third, fourth and fifth decks to accommodate 181 additional passengers (some reports say 117 passengers and some reports also say additional cargo capacity) and that the existing cabin spaces were also modified. It is reported that the modifications added 239 tons of weight to the vessel (some reports suggest 169 tonnes).

The Sewol is reported to have passed all required certification and safety checks following modification.

At the time of her last sailing, the Sewol was 146m long, 22m wide with a gross tonnage of 7000 tons. It could accommodate 921 passengers, 35 crew and space for 220 vehicles. It could also carry 152 20 foot shipping containers. It had a reported maximum speed of 21 knots.

The vessel is reported to have 46 lifeboats, but this probably means 46 liferafts. From the available photographs it is not clear if there are any davet lunched lifeboats.

On its final voyage it is reported that it was carrying more than 100 cars and lorries, along with a sizable shipment of cargo containers strapped onto the deck.

Detailed plans of the vessel, showing the layout of the interior and the location of the assembly errors are not available.

From BBC News website http://www.bbc.co.uk/news/world-asia-27087243

The occupants:

Reports of the total number of people on board during her final sailing varies from 359 up to 476.

The lower estimate is made up of: 30 crew, 325 students, 15 teachers and 89 other passengers. However, at the time of writing it is not known precisely how many people were on board.

Most accounts agree on the number of students at 325.

Students are from Danwon High School in Ansan, a suburb of Seoul

The voyage:

She was on a routine voyage which she usually undertakes two or three times per week.

The route runs from Incheon to the tourist island of Jeju.

The voyage is reported to last 13.5 hours (some reports say 14 hours).

On its last voyage, the Sewol sets sail from Incheon on Tuesday 15 April at night.

The conditions are reported as calm with a water temperature of about 12OC at the time of the incident.

It is expected that the passengers do not undertake an assembly drill prior to departure as the voyage is under 24 hours in duration. Thus by IMO regulations the shipping company is not required to hold an assembly drill.

The incident:

It is alleged that the Captain (68 year old Lee Joon-Seok) was not on the bridge at the time of the incident. This in itself is not an issue as the Captain cannot be expected to be on the bridge at all times. However, the question is whether or not this was a time requiring the Captain to be pilot the vessel.

It is alleged that the third mate, a 26 year old woman with one year’s experience at the helm of a vessel and five months experience on the Sewol is at the helm. It is alleged that this was the first time she had the helm of the Sewol.

It is alleged that the vessel made a sharp turn between 08:48 and 08:49. It is not clear why the sharp turn was made.

Passengers report hearing a bang and feeling a sever jolt.

A distress call is made from the Sewol at 08:56 (23:56 GMT) on Wednesday 16 April, vessel begins to heel over.

At around 09:30 the Sewol is at 600 heel and helicopters begin arriving.

At around 09:45 helicopters begin rescue operations.

At around 10:00 vessel is at 90O heel rescue operations continue.

At around 10:23 vessel is completely overturned.

During this period passengers report that they were instructed to remain where they were.

At the time of writing it is alleged that 46 people are confirmed dead, 174 rescued and 256 are missing.

Of the suggested 29 crew members on board, 20 including the Captain survived. It is alleged that the Captain was amongst the first to board rescue boats. Note that this does not mean that he was amongst the first rescued as helicopters allegedly rescued the first people.

From the Straits Times Web site: http://www.straitstimes.com/news/asia/east-asia/story/south-korea-ferry-disaster-fury-and-questions-grip

Speculation:

There are at least three possible causes for the incident:

1) The vessel hits an obstruction on the sea bed ripping open a hole in the vessel which suddenly takes on water causing the severe heel. The bang heard by the passengers was the sound of the vessel hitting the obstruction.

As this is a regular voyage on a regular route it is unlikely that the vessel would hit an obstruction on the sea bed unless the vessel was off course at the time of the incident.

The rescue divers may be able to eliminate option 1 if they are able to examine the hull of the submerged vessel.

2) The sudden turn made by the vessel is beyond the normal operational parameters of the vessel for the loading conditions causing the cargo to become dislodged

3) The sudden turn made by the vessel causes the vessel to lean into the turn destabilising the cargo and vehicles on the car deck which in turn accentuates the heel. The bang heard by the passengers is the shifting cargo on the vessel.

This may be an issue if the modifications to the vessel made the vessel less stable at normal operating situations by raising the centre of gravity of the vessel.

Alternatively, the cargo may have been incorrectly secured to the deck so that a sudden turn could have dislodged the cargo.

I would like to express my deepest sympathies to the families and loved ones of the 33 confirmed dead and the 174 still missing in the tragic incident on the MV Sewol off the island of Byungpoong South Korea on the 16 April 2014. My best wishes also go out to the many injured in the incident and the traumatised families of the dead and missing who must be overwhelmed with grief and anxiety. The loss of so many innocent people, mainly school aged children is a terrible tragedy which is felt not only by the families of those involved, but all the people of South Korea and the world. Thanks and praise should be heaped on the South Korean rescue workers who continue to search for survivors in extremely difficult conditions. Praise and admiration must also go out to the divers who are still putting themselves in harm’s way, as they attempt to search the flooded interior of the overturned vessel in the hope of finding survivors. Thanks should also go out to all those on land who are providing comfort and support to the survivors and the families of the bereaved and missing.

As in most disasters of this type, so soon after the incident, information concerning the nature of this incident is far too sketchy to draw any firm conclusions. Indeed, at the time of writing there are more questions than answers. Hopefully the inquiry into this incident will reveal what happened and why it happened. It is hoped that from this tragic incident lessons will be learned that will lead to the improved safety of those who take to the sea.

Our hearts and thoughts are with the innocent victims and the family and friends they left behind.
We honour the fire fighters and rescue workers who gave their lives.
We salute their colleagues who continue to put themselves in harm’s way.
Let their sacrifice be our spur to making the world a safer place.

Ed Galea
12 Sept 2001

Twelve years after the collapse of the WTC towers, the far-reaching impact of the attacks is still being felt when it comes to the design of new high-rise buildings across the world.

FSEG research is still on-going and the data we have collected, both on the mechanics of large-scale evacuation, and on the human behaviour issues, is being shared across the world, as a valuable international resource.

Using our buildingEXODUS evacuation software, we analysed the evacuation dynamics of the events of 9/11 and also explored what may have happened if the buildings had been fully occupied. From this work, we concluded that, for buildings above a critical population and height, stairs alone were not sufficient for safely evacuating the entire population.

Following this work, FSEG went on to explore the use of lifts for evacuation in high-rise buildings. We wanted to better understand the choices people make in deciding to use a lift/elevator as part of their evacuation route in an emergency. Using the knowledge gained from this research, we developed advanced human behaviour models, which simulate human behaviour in selecting to use a lift or stairs to evacuate, and if electing to use a lift, how long they would be prepared to wait for the lift before using the stairs. This model has been incorporated into the buildingEXODUS evacuation simulation software which now has the capability to explore the impact of lifts on high-rise building evacuation — but not only the mechanical aspects of using lifts, most importantly the human dynamics aspects.

Using the buildingEXODUS software, FSEG simulated a series of high-rise building evacuation scenarios in which the agents could elect to use lifts or stairs or a combination of both. This research suggests that combined use of stairs and lifts produce better evacuation times than simply using lifts alone. What’s more, if complex human behaviour is included in the evacuation analysis, the improved evacuation efficiency promised by lifts is not fully realised. This is because some people will not want to utilise lifts and opt for stairs, while other people who attempt to utilise lifts are not prepared to wait more than a few minutes. We know stairs alone are not sufficient for full building evacuations in large high-rise buildings. Since 9/11 there has been a trend to use specially designed elevators for evacuation in large high-rise buildings. But elevators, even fire safe elevators, raise the complex issue of human behaviour, and we know from our studies that many people do not trust using them, or will simply not wait for them, in an emergency. This is why it is important to have the capacity to utilise both lifts and stairs.

It is vital to take a holistic view of evacuation when designing new high-rise buildings. When it comes to elevators, this means not just the mechanical issues of using elevators to evacuate people, but the whole issue of human behaviour, and this is what we have built into the buildingEXODUS evacuation model. However, this is by no means the end of the story. More work needs to be done to understand the complex human dynamics issues associated with high-rise building evacuation dynamics.

Our analysis of stair travel speeds of people in the WTC evacuation suggested that people were not walking as fast as engineers may have expected. While our analysis suggested that the lower than expected travel speeds could be explained by the high crowd densities experienced on the stairs, it did bring into question whether the data that engineers have been using to characterise stair speed was out dated and inappropriate given the changes in population demographics in the 50 years since the data was first collected. As a result, FSEG have started to collect human performance data for people ascending and descending stairs. While still in the early stages of this work, some of the data that has already been collected suggests that stair walking speeds have indeed changed, at least for the younger demographic.

Twelve years on from 9/11, people need to guard against complacency. Evacuation drills and training always need to be taken extremely seriously, as successful evacuation depends in part on how quickly people respond. We found in our research that some people took many minutes to decide to evacuate the towers, while others didn’t know where the stairs were, for example. The attacks have also highlighted the need for better information systems in buildings, with proper instructions in an emergency, rather than just an alarm going off.

We hope that the insight we have gained into complex human behaviour issues in high-rise building evacuation since 9/11 will contribute to improving building design and evacuation procedures and so contribute to saving lives.

I think this is an interesting line of inquiry, but I don’t believe that the analysis presented addresses the whole picture and so can be misleading. The main point of the story is made in the opening sentences of the article, namely:

“More passengers are surviving fatal airline accidents during landing, but survival rates during stages of flight when most accidents happen have not improved from decades ago, a new USA TODAY study shows.”

I am quoted in the article as follows,

“Edwin Galea, a professor at the University of Greenwich in England who is an aircraft evacuation expert, said the USA TODAY study is “interesting” but omits some serious accidents without fatalities.”

However, this is only part of the concerns I conveyed to Mr Stroller. I have undertaken quite a bit of research on evacuation from aircraft including analysis of past accidents and appreciate how difficult it is to come to any meaningful conclusions when analysing aviation survival statistics (see publication list). While I do not doubt the accuracy of the data presented in the article, I believe that the analysis is potentially misleading. You have to look at the questions being asked, not just the answers being presented. I do not think the questions that are being posed in the article are quite right. My quotation in the article covers just one of my two main concerns. These are:

1) The USA Today analysis covers aircraft in which at least one person has died. So the analysis definitely includes what could be considered to be serious accidents. However, this is just a sub-set of serious accidents as it does it does not include serious accidents in which no one died, take for example just three recent accidents:

US Flight 1549 on 15 Jan 2009, an A320 out of LaGuardia heading to Seattle, carrying 150 pax and 5 crew. Aircraft was written-off after a forced landing on the Hudson River, there were five injuries, two of which were serious, yet everyone survived.

BA Flight 38 on 17 Jan 2008, a B777 coming in to land at Heathrow, carrying 136 paxs and 16 crew. Aircraft was written-off, there were 47 injuries, one of which was serious, yet everyone survived.

Air France Flight 358 on 2 Aug 2005, an A340 coming into land at Toronto, carrying 309 paxs and 12 crew. There was a serious fire and the aircraft was written-off, there were 12 injuries, yet everyone survived.

By anyone’s reckoning, these were three very serious accidents — so much so that in each case the aircraft was written-off – yet no one died. The USA Today analysis simply ignores these type of incidents and so incorporates a bias in the data.

2) The USA Today analysis includes accidents in which everyone on board died. Thus the analysis includes technically non-survivable accidents. These are accidents in which, given that the incident occurs, no feasible technological development is likely to improve the chances of survival as the trauma associated with the accident is simply too severe, for example:

The industry addresses these type of problems by introducing technological or procedural improvements to prevent them from occurring in the first place — prevention rather than mitigation. The issue here is reducing the frequency of these events from happening in the first place.

Mixing technically survivable and non-survivable accidents into the discussion on survivability in aviation accidents confuses the issue as advances in technology are not likely to impact survivability in non-survivable accidents. A clearer understanding of whether or not we are improving survivability in aviation incidents would be derived by splitting the discussion into two parts:

i) First, consider survivability in technically survivable accidents. The purpose of this investigation is to establish whether or not your chances of surviving a survivable crash is getting better or worse as a result of the advances in technology and regulation. Related to this would be determining how likely you are to be involved in a survivable crash and whether or not this is improving.

ii) Secondly, consider the frequency of technically non-survivable accidents. The purpose of this investigation is to establish how likely you are to be involved in a non-survivable crash and whether or not advances in technology and regulation are improving these chances.

It is essential to filter the raw aviation accident data in an appropriate and meaningful way if truly meaningful conclusions are to be drawn as to the current state of aviation safety and whether or not it is improving.

Questions are being raised as to how many people were in the nightclub at the time of the incident. This will become an important issue as the inquiry into the disaster progresses as the level of club occupancy could be used as a factor in contributing to the severity of the disaster and hence in apportioning responsibility. Another issue that has been raised is whether or not more exits would have made a material difference to the outcome. To examine these issues we can do some simple analysis based on a number of assumptions and what the media are currently reporting.

So what do we (think we) know about the Kiss fire incident according to accounts in the media:

1) The club has a floor area of 615 m2. However, it is not known how this breaks down to dance floor, bar, toilets, circulation space etc.

2) The maximum travel distance to the front door is reported as being 32m.

5) The club owner insists that there were only 600 to 700 people in the club at the time of the incident. However, the band’s guitarist told media that there were between 1200 and 1300 people in the club at the time and the police have given the same estimate. The owner suggests that the higher estimates are due to clubers cycling into and out of the club.

7) According to what I understand to be the fire certificate, the club is credited with having 2 emergency exits — hence 3 exits in total, one main and 2 emergency. However, this is not clear from the article which later refers to these ‘emergency exits’ simply as ‘exits’, in which case the club may have been certified as having 2 exits, 1 main and 1 emergency exit. So it appears from the media accounts that the club was certified as having 3 or 2 exits — depending on the interpretation of the article.

Furthermore, it appears that the expired license has been reported as suggesting that the club had three (or at least two) exits. Unless the missing exit or exits have been bricked up since the license was issued, or that the exit(s) were there but were locked or blocked during the incident and so could not be used, how could a license be issued stating that the club had three (or two) exits? One has to ask if inspections of the club were ever performed. If they were performed, how could an inspector fail to notice that two (or one) exits were missing?

Given that the nightclub had only a third of the legally required number of exits, one has to wonder whether this would have made a material difference to the outcome.

Concerning the number of people in the club, this is important as it is the manager’s responsibility to control the number of people in the club. The manager suggests that the there were 700 people in the club, as allowed by the questionable ‘license’. If there were 700 people in the club, this would be of benefit to the manager as it suggests overcrowding — his responsibility — would not have been a major factor and refocuses attention on the questionable fire license. If there were 1200 people in the club, this deflects some degree of blame from the band — for allegedly starting the fire using flares — and for the code enforcement agency for permitting the license in the first place.

Is it likely that there were 1200 people in the Kiss Nightclub at the time of the incident?

SIMPLIFIED ANALYSIS:

Let’s do a simplified analysis on numbers of exits and number of people. Note that this analysis is crude and a more thorough analysis would be required to establish the relevance of these key parameters. The simplified analysis is dependent on a number of simplifying assumptions detailed below.

1) Assuming the 3m available exit width and a population of 1200 and 700, approximately how long would it have taken for the population to get out?

Let’s simplify the calculation and assume the population reacts immediately (zero response time) and let’s also assume that all the people are queued up at the exit ready to go. Assuming a unit flow of 1.33 p/m/s (UK ADB) then the exit could sustain a flow of 3.99 p/s and it would require:

- at least 300 s for 1200 people to exit and

- at least 175 s for 700 people to exit.

2) How much time would be available for people to get out? This is extremely difficult to estimate without doing a detailed analysis. But let’s use the Rhode Island Nightclub fire as a rough guide. After about 100 s conditions in the Station Nightclub were non-survivable. The floor area of the Station Nightclub was about 412 m2 and so the Kiss nightclub is some 50% larger. Based on this let’s assume that people had 50% longer to get out, making it 150 s for non-survivable conditions to develop. This is admittedly a very crude estimation and may over estimate the amount of time available.

In 150 s, using the single available exit we could expect about 600 people to get out:

- generating a death toll of 100 people assuming there were 700 people in the club, as claimed by the manager,

- generating a death toll of 600 people assuming the band/authorities are correct and there were 1200 in the club.

Given the current death toll of 235, it is possible that there were 835 people in the club. If correct, this would suggest that while the club was overcrowded, it is unlikely that there were as many people as suggested by the band/authorities.

A note of caution, remember, the assumptions that have been made are rather crude. The population is unlikely to have had zero response times, but evidence from the Rhode Island fire would suggest that in these types of situations, occupant response times are quite small of the order of a few seconds. We can slightly improve these approximations by relaxing the zero response time assumption and assuming that the first people start to move in 10 s and that the closest people to the exit are located a third of the maximum distance (11m) and that the people located here move at 1.1 m/s. This would add about 20 s to the estimated exit times OR reduce the available safe egress time by 20 s. So let’s assume that we have 130 s to get out.

In 130 s, using the single available exit we could expect about 519 people to get out:

- generating a death toll of 181 people assuming there were 700 people in the club, as claimed by the manager,

- generating a death toll of 681 to be killed if the band/authorities are correct and there were 1200 in the club.

Given the current death toll of 235, it is possible that there were 754 people in the club. This would shift the club occupancy even closer to that suggested by the nightclub owner.

We may also assume that the unit flow achieved by the exit was better than that prescribed in the UK regulations, which by their nature are conservative. This would get more people out of the nightclub within the 130 s available time, increasing the size of the estimated population within the club. However, in such situations, especially after the first few people have exited, the exit flow will become competitive rather than ordered, which will tend to reduce the exiting efficiency and hence the achieved unit flow rate. In reality, the unit flow rate achieved by the exit will vary throughout the evacuation, being somewhat greater than that specified by the regulation at the start of the evacuation and being somewhat less towards the end of the evacuation. Without undertaking a detailed analysis it is difficult to suggest a reasonable value for the unit flow rate, so for the purposes of this blog we will keep it as it is.

It is worth noting the following:

- if the average unit flow rate of the exit is greater than that used in these calculations, more people would have been able to exit in the available time and hence the estimate of the club occupancy would go up,

- if the average unit flow rate of the exit is less than that used in these calculations, fewer people would have been able to exit in the available time and hence the estimate of the club occupancy would go down.

Given the uncertainties I will stick to the initial estimates.

3) What would have happened if there were the legally required 3 exits in the club? To answer this requires us to know the total available exit width. Let’s assume that the club would have followed UK requirements. An assembly space of more than 600 people would require 3 exits (as apparently does the local requirements). Using BS 9999, the minimum total exit width for the 3 exits would be 4.3m. Here we assume that all three exits have the same width.

If we make similar assumptions to that in (1) and in addition that all three exits were available and the population is equally divided between the three exits, then the combined flow would be 5.7 p/s and :

- 700 people would be able to exit in 123 s

- 835 people would be able to exit in 147 s

- 1200 people would be able to exit in 211 s

Assuming the same amount of time is available for safe egress i.e. 150 s, then:

- all 700 people would be able to safely evacuate, i.e. the legal occupancy would have been able to safely evacuate.

- all 835 people who are estimated to have been in the club would have managed to safely evacuate

- of the 1200 people, 855 would manage to get out, and the death toll would have been 345.

So these simplistic calculations suggest that if the club and the legally required minimum number of exits (3) with an exit width as specified by the BS 9999 and:

- the legal maximum population (700), then it is possible that everyone would have managed to evacuate before conditions in the club became non-survivable.

- if the population of the club was 835, then it is possible that everyone would have managed to evacuate before conditions in the club became non-survivable. So even though the club was overcrowded on the night, it is possible that everyone would have managed to evacuate.

- if the population of the club was 1200, the population suggested by the band/authorities, then it is possible that 855 people would have managed to evacuate before conditions in the club became non-survivable and 345 people would have died. So if the population was as high as 1200, even if the legally required exit capacity was provided it is unlikely that everyone would have managed to evacuate.

It has to be emphasised that these calculations are extremely crude, but they serve to demonstrate how important it is establish the correct number of people that were in the club at the time of the incident. They also demonstrate that had the club had the required number of exits, it is possible that the death toll in this incident could have been significantly reduced.

To do a more thorough analysis on this incident would require fundamental data describing the club and the materials within the club, the number of people in the club and their distribution. With this information it would be possible to undertake sophisticated fire and evacuation analysis of the type undertaken for the Rhode Island Nightclub fire.

The death toll in the Kiss Nightclub fire has risen to 231. It is heart breaking to see so many young faces with promising lives ahead of them snuffed out in seconds. The names of the victims are listed on a Brazilian newspaper website along with their photos:

It is even more heartbreaking to learn that this tragic loss of life may have been needless and preventable. As more details of this tragedy begin to emerge, heartbreak turns to anger. While the details are still not known for certain, the more that comes out in the media the more this carnage appears to have been a preventable tragedy and a failure of regulation, enforcement and management.

What do we know from the reports in the media:

1) From CNN we are told that the club’s license had expired in August 2012 and had not been renewed. We are also told that the owners had said that the club was properly permitted and had been inspected by the fire marshal.

This suggests that at least up to August 2012 the club had been considered appropriate and compliant with the local codes.

2) It has been reported in most media accounts that the club had only one exit. In some media accounts the word emergency exit has been used, which suggests that there may be at least two exits, while in other accounts it has been categorically stated that the club had just one exit.

4) While it is still not confirmed, it now appears likely that the band did make use of pyrotechnics during their show, and this was a well known feature of the band. Reports have even suggested that they made use of three flares.

However, the fire cause is not known at this stage. It may, as media accounts suggest, have been caused by the pyrotechnics, or it may have been caused by an electrical fault. We simply do not know at this stage.

Taking these points one can begin to ask some questions concerning the Brazilian fire safety regulations, the enforcement of those regulations and the quality of the management at the club.

REGULATIONS and ENFORCEMENT:

a) How could Brazilian building regulations (or the local code) permit a place of public assembly, with a reported capacity of 1000 people, to have only a single exit? Even though the license had expired and was under review, the club was considered compliant up to when the license expired in August 2012, so the exit capacity was deemed to be acceptable. Furthermore, what total exit width is required by regulation? With a capacity of 1000 people I would have expected at least three exits with a total exit width of at least 6m.

b) It appears that no fire alarm sounded. Was this because the alarm failed or did the club not have an alarm? If the club did not have an alarm, how could the building regulations possibly permit this? Had an alarm sounded, perhaps the security guards would not have initially prevented people from escaping, possibly reducing the death toll. If the club had an alarm was it operational prior to the fire? If not, could this have been overlooked during a fire inspection?

c) It is reported that the exit route was dark. Was there no emergency lighting in the club or did it fail? If there was no emergency lighting how could this be permitted by the regulations? Had emergency lighting been available, perhaps people would not have tripped in the exit path and perhaps people would not have mistaken the toilets for an exit route. If the club had emergency lighting was it operational prior to the fire? If not, could this have been overlooked during a fire inspection?

Schematic of the Kiss Nightclub

d) What does the Brazilian code require in terms of emergency exit signage? Is this required? Had it been in place, perhaps so many people would not have mistaken the toilets as a means of escape. If emergency exit signage was required by law and it was in place, was it operational prior to the fire? If not, could this have been overlooked during a fire inspection?

e) The fire appears to have started in the sound proofing foam that lined the ceiling and spread rapidly producing large amounts of toxic fumes. What type of foam was this? Was it protected in some way e.g. coated or covered with a fire resistive material? What do the Brazilian fire regulations say about the type of foams that can be used in places of assembly? If the use of foam is permitted, was the foam in place compliant with standards prior to the fire? If not, could this have been overlooked during a fire inspection?

f) What do Brazilian regulations say about the use of indoor pyrotechnics? If like most countries they permit the use of such devices, what provisions are made to limit their use and ensure that they are used in a responsible manner? Concerning the use of flares, surely this cannot be permitted?

g) Is it required by Brazilian fire regulations to regularly inspect mandatory fire fighting equipment? If so, what is the frequency? If regulations stipulate they are to be inspected, were the fire extinguishers in the club inspected prior to the fire?

MANAGEMENT:

a) It is reported that the maximum occupancy for the club was 1000, yet fire authorities suggest that there could have been as many 1500 people in the club. What means did management have to ensure that the number of people in the club did not exceed their license limit?

b) If the use of pyrotechnics are permitted under Brazilian code, what measures did the management have in place to ensure their safe use?

c) It is reported that fire extinguishers failed to operate. Did the club management have the fire extinguishers serviced on a regular basis?

d) What training did the club staff have in terms of fire fighting and crowd management?

These are just some of the questions that need to be answered if the root causes of this tragedy are to be addressed. It is possible that this tragedy was no accident i.e. an unforeseeable event, but the result of a predictable and preventable failing of Regulation, Enforcement and Management. If so, then immediate measures must be taken to correct the failings in order to ensure a safer Brazil – let this be the legacy of the Kiss Nightclub victims.

Finally, this tragedy provides a couple of hard learnt lessons for the rest of the world:

1) Stop the use of pyrotechnics indoors, they are just too dangerous.

2) Inspection and enforcement must be taken as seriously as legislation.

Today we hear the news of a tragic nightclub fire in Brazil which has claimed the lives of at least 180 young people, with at least 200 more injured. The fire is reported to have occurred in the early hours of the morning of the 27 January in the Kiss Nightclub in Santa Maria,Rio Grande do Sul in southern Brazil. According to unconfirmed reports in The Independent newspaper, the fire allegedly started when a band member started a fireworks display on stage which set alight sound proofing. While the nature of the sound proofing has not yet been confirmed, it was probably (untreated) Polyurethane (PU) foam, which is cheap to obtain and easy to put up. If correct, this will be frighteningly similar to the Station Nightclub fire in Rhode Island USA of February 2003 which claimed the lives of 100 people and injured over 200 others.

In the Rhode Island case, fire works started by the band set alight PU foam which was used as sound proofing cladding on the walls. The PU rapidly burnt producing thick choking smoke, laden with deadly Carbon Monoxide gas and Hydrogen Cyanide gas. People were rapidly overcome by the toxic gases and the rapid resulting flashover. Coupled fire and evacuation computer simulations of the Rhode Island nightclub fire produced by FSEG suggest that after approximately 100 seconds from ignition, around 100 people would be dead due to the inhalation of toxic fire gases and the effects of flashover. In the Rhode Island case, while the club was full, it was within legal limits and the nightclub had four exits (including the main exit), but the majority of the patrons tried to use the main entrance, the exit that they used to come into the club.

Media accounts are suggesting that between 300 and 2000 people were in the Kiss Nightclub at the time of the fire. It is also not clear how many exits the nightclub had, media reports suggest that the nightclub had only one emergency exit and that fire fighters had to make a hole in the wall to assist people to escape. As the Rhode Island Nightclub fire demonstrated, fires in such environments, fuelled by PU foam will spread extremely rapidly producing large amounts of highly toxic gases, providing people in the crowed venue little time to get out.

If the reports in the media are correct, then it is surprising that only 180 people have lost their lives. I would not be surprised if the death toll rises, especially if the occupancy is more than 300. Large crowds, within a confined space, whose walls are clad with combustible PU foam, with limited means of egress, probably in the dark, a number of who are probably intoxicated and then allowing the use of pyrotechnics is a recipe for disaster. Indeed, building regulations and planning permission should not permit such death traps to exist in the first place and enforcement authorities should ensure that they do not occur.

Once the blame game starts, I hope that the bereaved families do not simply point their finger at the nightclub owner but look beyond this, to their local government authorities that have responsibility for planning permission and building control and to enforcement authorities that have responsibility for inspecting premises. It is too easy to simply blame the owner. More importantly, to do so will simply allow this type of tragedy to happen again and again.

Furthermore, while this type of disaster can happen anywhere in the world, and it has — USA, Russia, China and Argentina to name just four recent disasters – it is to be hoped that a country with the responsibility of hosting the next Football World Cup and the Olympics, will ensure that their building regulations and the enforcement of those regulations are fit for purpose. Not simply for the new build stadia, but for all the existing hotels, transportation hubs and entertainment venues that will be enjoyed by millions of tourists from around the world.

Finally, I wonder how long it is going to take before the media, and local government officials begin to attribute “panic” as a contributory factor in this tragedy, conveniently diverting attention from other potential systemic failures.

Getting passengers to pay attention and understand the airline safety briefing is always a struggle. I think that the most important information currently conveyed to passengers concerns the brace position, emergency lighting and the location of the exits. Some information not provided during the briefing is that not all the exits on your aircraft are necessarily the same size. On aircraft such as the B737 and A320, it is also important to understand that not all the exits are the same size – the ones in the middle are small and so it will take you longer to get out using these exits.

Part of the problem is getting the passengers engaged enough in the safety briefing so that they pay attention and potentially learn something that could save their lives in the event of an accident.

Shown here are two safety briefings from the same airline, Air New Zealand. Both are a little different from your ordinary in-flight briefing. Both try and capture your attention in the hope that you will engage in the safety messaging.